Echocardiography for hemodynamic evaluation in the intensive care unit

Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Shock (Augusta, Ga.) (Impact Factor: 3.05). 09/2010; 34 Suppl 1(Suppl 1):59-62. DOI: 10.1097/SHK.0b013e3181e7e8ed
Source: PubMed


The use of echocardiography in the intensive care unit for patients in shock allows the accurate measurement of several hemodynamic variables in a noninvasive way. By using echocardiography as a hemodynamic monitoring tool, the clinician can evaluate several aspects of shock states, such as cardiac output and fluid responsiveness, myocardial contractility, intracavitary pressures, and biventricular interactions. However, to date, there have been few guidelines suggesting an objective hemodynamic-based examination in the intensive care unit, and most intensivists are usually not familiar with this tool. In this review, we describe some of the most important hemodynamic parameters that can be obtained at the bedside with transthoracic echocardiography.

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Available from: Claudio Henrique Fischer
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    • "Echocardiography has been established as a tool to evaluate the causes of hemodynamic instability in ICU patients by the visualization of cardiac chambers, valves and pericardium and cardiac functional abnormalities [4,5]. Transthoracic echocardiography (TTE) can be used as a first-line approach for a quick and focused examination to diagnose acute cor pulmonale, cardiac tamponade or major left ventricular systolic dysfunction [6]. "
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    ABSTRACT: Hemodynamic management in intensive care patients guided by blood pressure and flow measurements often do not sufficiently reveal common hemodynamic problems. Transesophageal echocardiography (TEE) allows for direct measurement of cardiac volumes and function. A new miniaturized probe for TEE (mTEE) potentially provides a rapid and simplified approach to monitor cardiac function. The aim of the study was to assess the feasibility of hemodynamic monitoring using mTEE in critically ill patients after a brief operator training period. In the context of the introduction of mTEE in a large ICU, fourteen ICU staff specialists with no previous TEE experience received 6 hours of training as mTEE operators. The feasibility of mTEE and the quality of the obtained hemodynamic information was assessed. Three standard views were acquired in hemodynamically unstable patients: 1) for assessment of left ventricular function (LV) fractional area change (FAC) was obtained from transgastric midesophageal short axis view, 2) right ventricular (RV) size was obtained from midesophageal four chamber view, and 3) superior vena cava collapsibility for detection of hypovolemia was assessed from midesophageal ascending aortic short axis view. Off-line blinded assessment by an expert cardiologist was considered as reference. Interrater agreement was assessed using Chi-square tests or correlation analysis as appropriate. In 55 patients, 148 mTEE examinations were performed. Acquisition of loops in sufficient quality was possible in 110 examinations for transgastric midesophageal short axis, 118 examinations for midesophageal four chamber and 125 examinations for midesophageal ascending aortic short axis view. Interrater agreement (Kappa) between ICU mTEE operators and the reference was 0.62 for estimates of LV function, 0.65 for RV dilatation, 0.76 for hypovolemia and 0.77 for occurrence of pericardial effusion (all P<0.0001). There was a significant correlation between the FAC measured by ICU operators and the reference (r = 0.794, P (one-tailed) <0.0001). Echocardiographic examinations using mTEE after brief bed-side training were feasible and of sufficient quality in a majority of examined ICU patients with good interrater reliability between mTEE operators and a expert cardiologist. Further studies are required to assess the impact of hemodynamic monitoring by mTEE on relevant patient outcomes.
    Full-text · Article · Jun 2013 · Critical care (London, England)

  • No preview · Article · Sep 2010 · Shock (Augusta, Ga.)
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    ABSTRACT: The intrathoracic pressure regulator (ITPR) (CirQLator; Advanced Circulatory Systems Inc, Roseville, Minn) is a novel, noninvasive device intended to increase cardiac output and blood pressure in hypovolemic or cardiogenic shock by generating a continuous low-level intrathoracic vacuum in between positive pressure ventilations. Although there are robust data supporting the benefit of the ITPR in multiple animal models of shock, the device has not been used in humans. The goals of this study were to evaluate both the safety and efficacy of the ITPR in humans. Twenty patients undergoing coronary artery bypass graft surgery were enrolled in this phase 1 study. Intraoperative use of both pulmonary artery pressure monitoring and transesophageal echocardiography (TEE) was required for study inclusion. Hemodynamic variables as well as TEE measurements of left ventricular performance were collected at baseline and after the ITPR device was activated, before surgical incision. Thermodilution cardiac output increased significantly with the application of the ITPR (4.9 vs. 5.5 L/min; P = 0.017). Similarly, cardiac output was measured by TEE (5.1 vs. 5.7 L/min; P = 0.001). There were significant increases in pulmonary artery systolic blood pressures (35 vs. 38 mmHg; P < 0.001) and mean pulmonary artery pressures (24 vs. 26 mmHg; P = 0.008). There were no significant differences in systemic blood pressures, left ventricular volumes, stroke volume, or ejection fraction as measured by TEE. Using two different measurement techniques, application of the ITPR increased cardiac output in normovolemic anesthetized patients who underwent coronary artery bypass graft before sternotomy. These data suggest that the ITPR has the potential to safely and effectively increase cardiac output in humans.
    No preview · Article · Jan 2011 · Shock
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